ICD-10 Documentation Tips for Radiologists

September 22, 2015

With ICD-10, additional specificity will be required in order to support the medical necessity of many radiology exams. As ADVOCATE has discussed previously, the radiologists are at a particular disadvantage because of their lack of face to face time with the patient and inability to acquire a complete clinical history. We continue to advise that in order for the ICD-10 transition to be successful for the radiologist, there must be a collaborative effort with the hospitals, technologists, and referring physicians to ensure the radiologist is obtaining the most accurate and specific clinical information for each patient. For more details on this, refer to our previous E-News addressing clinical history. Click here to view.

Aside from the clinical history, how else can the radiologist improve documentation to prepare for ICD-10?

Here are some basic strategies for radiologists to help ensure improved documentation required with ICD-10.

Develop awareness of poor clinical history (is it a specific location, technologist, referring physician, etc.). Communicate regularly if the clinical history is insufficient or incomplete.

Utilize any clinical documentation that is available in PACS, such as tech notes, check-in sheets, order, etc. Develop habits to review this information and dictate pertinent clinical history details in report.

Document laterality when appropriate.

Document specifics for fractures and injuries:

Specific site of fracture/injury

Type of fracture

Episode of care (is this a current fracture or followup/aftercare/malunion?)

Remember the basics of ICD-10 documentation. Whenever possible, document the following specifics: